Episode 7 Island Medics

Shetland. The most remote part of the UK.

Here, you're closer to the Arctic Circle than you are to London

and nearer Norway than you are to Edinburgh.

There are more puffins than people

and more seals than supermarkets.

But this wild landscape is also home to 23,000 islanders.

They're so far from the mainland that when things go wrong...

A&E, can I help you?

..from helicopter rescues and spinal injuries...

We're all here to make sure that you're OK.

..to serious medical mysteries...

Can we get assistance in, please?

Something's not right.

..Shetland's island medics have to be ready

for anything and everything.

-What happened?

-Got in a fight with a seagull.

-This was sheep shears, was it?

-Yes.

It means the tight-knit team of medics,

volunteers and emergency services have a special bond.

This might tickle, then.

And they know just how to keep each other going...

A wee treat for night shift.

..so they're always ready for any island emergency.

Today on Shetland,

there's a case that piques nurse Emma Williamson's interest...

I've got a problem with my pacemaker.

That already sounds a bit exciting!

..crofter Andy has an accident with his sheep shears...

Got a shower and came here, but I can still smell sheep on me!

..and offshore worker Ryan has some worrying appendicitis symptoms.

On Shetland, it's fair to say there's plenty to do

for locals and tourists alike.

This rugged group of over 100 islands

provide residents with opportunities

like few other places in the British Isles.

As well as the offshore industries and a growing tourism sector,

traditional jobs like farming and fishing are having a renaissance.

With such an eclectic mix of industries,

it means an array of unique injuries and ailments can come through the

doors of the Gilbert Bain Hospital.

In the accident and emergency department,

a patient has walked through the doors

with a distinctly Shetland injury.

I was just clipping sheep and it kicked the shears out of my hand

and I think, instantly, by instinct, I tried to grab it with this

and just caught the end of the shears.

Just snipped the end of my finger.

-Carried on shearing.

-Aye, course you did!

I've had worse. I've had sheep shears up my arm

and that was stitches.

Seems a waste of time,

to waste a doctor's time on that.

Andy, who is originally from Leeds,

moved to Shetland almost 40 years ago.

He now lives on the isle of Brae to the north-west of Lerwick.

Together with his wife, Barbara,

they work the 90 acres of her family's croft.

It can be a dangerous business

looking after their 40 sheep and Highland cattle.

Oh! So this was sheep shears, was it?

Yes, electrical ones, yes.

Oh.

It'll be up to Dr Kirsty Sneddon and nurse Lauren Kerr to treat the

wound and, most importantly, make it safe from infection.

So you've got the flap, but the flap's split in two.

-Oh, yes?

-And see this side, the darker side,

I think you're probably going to lose that

-and that's going to scab over.

-OK.

I think a Steri will probably hold it.

It's kind of splitting three ways.

-Mm-hm.

-This flap.

-And I could do one from there right over.

You could try that.

And then what do you think for follow-up?

How dirty were the shears?

Er, not TOO bad.

Were they in use?

They were in use, yeah.

I had clipped about five...

So I think we need to be a bit more careful.

We'll give it a good wash-out, but there is a risk that, you know,

it's not like you've just pulled them out of the packet.

-No.

-They've been used on livestock.

-They've been used, yeah.

-The issue is that if the bone underneath gets infected.

-Yes.

Maybe try not to cut any more limbs!

No, I've finished! I carried on and finished them,

then got a shower and came here, but I can still smell sheep on me.

I can't!

Steri-strips are used for small lacerations

and are a useful alternative to stitches.

But before the strips can be applied,

a thorough clean by nurse Lauren Kerr is needed.

So, this is a Betadine solution, so it's just an antiseptic solution.

Just cos he's cut it on shearing shears that's been used with

livestock, so they are dirty,

so we just need to make sure it's got a good clean

so that it hopefully doesn't get infected.

If it stings as much as under the tap, you're going to see me cry!

Soak it in there. Is it stinging?

Yes, a little bit. It's OK.

-I think it is actually quite clean.

-Yeah, and it bled a little.

-And it bled.

-Yeah, so that should have flushed something out.

And then you've had a pressure bandage on it till you've got here,

so you've done everything.

With the laceration thoroughly cleaned,

nurse Lauren applies the Steri-strips.

-Is that OK right there?

-Yeah, yeah, that's fine.

So that should keep it together quite nicely.

I think that will be fine, cos that's the main bits

we're trying to keep together.

This comes down so it doesn't... so when we take it off,

it doesn't stick as much when they take it off.

So it's going to come down like that.

It's fine and neat as well, so it's not really bulky.

-This just rolls down, OK? Sorry if it's uncomfortable.

-That's OK.

-No, it's fine.

-So if you can try and keep this dry, obviously.

-Is that OK?

-Yeah, that looks lovely, thanks.

If there's any signs of infection, like redness, swelling,

extreme pain or anything out of the ordinary,

then I would say to get to your GP sooner,

or come back here if you can't get an appointment,

just because it has been cut with dirty scissors.

-Yeah.

-And I'll go and get you that information sheet.

-OK.

Andy's sheep shearing injury's cleaned and dressed.

Yeah. And I didn't cry!

He is under strict instructions to give the woolly clippers a break

for at least a little while.

-Much appreciated, thank you.

-See you later. Bye.

Happy customer!

CAWING

Whether you're a crofter or a tourist, if you need

medical care on Shetland,

you'll have the option of visiting the only hospital,

the Gilbert Bain in Lerwick.

Up there for me.

Or you can visit one of the ten health centres

among the communities of Shetland.

The health centres provide GP surgeries

and several community-care services to residents.

Maintaining stocks of vital vaccines and medical supplies is a job

organised from the Gilbert Bain.

Morning, morning.

So, first part of the day is mail.

Another day, another dollar.

It's the start of the day for hospital porter John Hallam.

Today, he's the man responsible for keeping Shetland's health centres

supplied with important vaccines and medication.

First of all, I've got to pick up all the supplies from the stores.

Drugs from pharmacy.

Yeah, we do about 300 miles a week.

And three ferries.

John moved up to Shetland 16 years ago from the Peak District,

looking for a quieter life.

We came up here in 2001...

..and I don't miss the commotion.

I mean, look at this.

This is it.

So, that's rush-hour. About ten minutes, yeah.

It's just amazing. Carolyn, my wife's, a midwife

and we lived in the Peak District

with a million-plus visitors a year,

so they say. We couldn't get out of the house at the weekend.

Yeah, we'd had enough.

It was something better for the kids.

So here we go.

To get on the road, John needs to load up his van

with medical supplies from the hospital depot.

OK, so we've got today's.

That's for tomorrow and they've not started on Friday's yet.

I'll take this back and we'll be away.

I think it's going to be a quiet day today.

Right.

Porters, see what they've got.

-Just gas?

-Yeah.

John visits different hospital departments

to collect anything that's been requested by the remote surgeries.

-Oxygen?

-Oxygen.

-Yeah.

-All yours, John.

-Thank you very much.

-And one bit of paper for them to sign.

-Ta.

With just a few more pick-ups required,

John needs to collect the internal post.

-ELEVATOR:

-Doors closing.

-Good morning.

-Morning.

The early bird catches the worm.

Good morning. You've got a cold?

-Yeah.

-Well, stay where you are. Don't come near me.

And finally, the all-important vaccines.

Okey dokey. Thanks very much.

Cheers, now.

So, this is... There's just some for Bixter today,

in what I call my lunchbox.

This is the drugs that have to be kept cool.

Got about an eight-hour lifespan in here.

That one's going to Bixter,

so it's my second port of call after Levenwick.

Finally on his way, John has three main clinics to visit today.

So, this is us on the way to Levenwick, yeah.

20 minutes.

The weather, changeable.

Very changeable.

Yeah, it's nice.

I just miss trees

and I miss mountains.

I don't miss the traffic jams.

Well, I've been up here 15 years.

And a lot of people I know have been to this island a couple of times,

visited it on holiday,

and they go, "Oh, I'd love to come and live here."

Fabulous. Yeah.

Yeah. No hold-ups, no problems.

Laid-back.

Yeah.

Laid-back. You haven't got the stress of down south.

With a stop in Levenwick in the south and Bixter and Walls

in the north-west, John will be travelling the length and breadth

of mainland Shetland.

With so many oil and gas rigs lying off the shores of Shetland,

it's no surprise that the Gilbert Bain A&E department

often plays host to their workers.

19-year-old Ryan has been medevac'd

from the rig he works on after several

days of vomiting and abdominal pain.

Nurse Kathy Duffus is the first to assess him.

The medic on board thinks he might have appendicitis.

He felt a bit faint on the helicopter

and dropped his blood pressure,

so I slid him across because when he sat up in here,

he passed out again.

So just quickly get him checked out.

But he's fully conscious and speaking to us

and he's not in any pain, so we'll see how he is.

-Right, take care, mate.

-Thank you.

Cheers.

-Thank you.

-Appendicitis is an inflammation of the appendix

and left untreated or misdiagnosed, it can be a very serious condition.

It's up to Dr Caitlin Brennan to assess Ryan.

I think we need to get some blood tests to see whether he does have an

infection on board and we'll examine him

and see if he does have a sore tummy.

Hello. So is it Ryan?

Yeah. I started getting pain from my right side to my left side

in the middle of my belly.

And then, yesterday, the pain just got worse on the right side.

And how many times have you had diarrhoea now?

Quite a few times. I've not been able to count.

So, more than ten, or...?

It was maybe less than ten, I would say.

-Maybe.

-And vomiting as well?

-Quite a few times, yes.

Have you been able to keep anything down that you've eaten or drank?

No, no.

Dr Brennan inspects Ryan's abdomen.

My hands are freezing. They're always freezing!

So if I press on this side, is it sore on the other side at all?

-Just a wee bit.

-A wee bit.

-Mm-hm.

-OK.

It starts to get...

-Yeah.

-And that's quite painful?

-Mm-hm.

-It's a bit horrible, but is it sorer if I press...

-Yeah.

-..or if I let go?

-When you press.

-So, if you just lift this leg up.

-Any pain there?

-Yeah.

-Where do you feel it?

Just in here, I think.

-Down there.

-And when we're doing that?

-Yeah.

Good.

So, it's all a bit up in the air at the moment, but once we know,

-we'll let you know, OK?

-Okey doke.

-All right.

With Dr Brennan's initial examination complete,

she turns to senior A&E doctor Kushik Lalla for advice

on diagnosing Ryan's symptoms.

That's the problem with appendicitis.

No matter how experienced you are, you will get caught out,

and if you haven't been caught out by appendicitis,

you haven't seen enough appendicitis.

You have to be very, very suspicious.

Appendicitis can be difficult to diagnose due to the position

of the appendix and its size

and symptoms can be similar to other inflammatory problems.

Dr Lalla needs all the information Dr Brennan has gathered.

Pain seemed to come on at the same time as the diarrhoea.

OK, so it wasn't pain first and then diarrhoea?

So, pain and diarrhoea concurrent.

-OK, yeah, OK.

-He's been away for ten days on the rig

and no-one else is unwell. Family history,

some sort of bowel history, which he doesn't think was cancer.

-So, it could also be colitis.

-Could.

Could. It's sounding more like that sort of picture,

rather than appendicitis.

But, yeah. The family history's important here.

It's very likely that he is going to end up with either,

it's going to be Crohn's or ulcerative colitis,

one of those two.

Crohn's disease is an inflammation of the digestive tract

and can cause serious complications for sufferers.

If it IS Crohn's, it could be life-changing for Ryan.

Staff nurse and Shetland native Emma Williamson is on the day shift

in A&E. As can often be the case,

it's not long before a patient is knocking on her door.

-Oh, hello.

-Hello.

-Hi, how can we help?

I've got a little problem with my pacemaker.

-Oh!

-Oh!

-That already sounds a bit exciting!

Me wires have come through the skin.

Ooh! When did you get it put in?

-November?

-Last November.

-Has it been gradually coming through?

-Yes.

-Yeah.

-Well...

I've been keeping an eye on it but this morning, when he had a shower,

there was like a clear, liquidy-stained plasma coming out.

Coming out of it.

It looks like a little hole.

Oh, OK.

Alan and Janine have travelled in from Sandwick,

13 miles south of the Gilbert Bain.

They are concerned the wires of Alan's pacemaker

have started to protrude through his skin.

For nurse Emma, it's another unusual story to add to the list.

If you actually take time, you get

so much more for your patient in here.

Their background, their story, and what has brought them in.

And often there are really some very fascinating stories

from these folk and I love to hear them.

Does it feel like it's working all right?

-Yeah.

-Doesn't feel like it's doing anything weird and wonderful?

No. I've had problems with wires in the past,

where it's come off,

and it's been short-circuiting through my shoulder.

Alan had his first pacemaker installed in 1998.

Since then, it's fair to say he's been through quite a few.

Well, I've had nine pacemakers in.

-In total?

-Yeah.

-Oh, my goodness!

I think that's a record for me looking after somebody.

The first one I got came out the skin underneath my armpit.

Your body obviously likes to work it out!

Yeah. I need a bit more fat on me, I think.

We'll feed you up. Me and Amanda don't have that problem,

-we were saying that to somebody else.

-Thanks!

I'll going and phone the doctor, then.

-OK.

-Oh, I'll give you a buzzer, actually.

If you feel funny at all, or you need us...

What's your wife's name?

-Janine.

-I'll let Janine come and sit with you, all right?

This is a gentleman who has had lots and lots of contact

with NHS services. He's had a nine pacemakers.

I don't think I've ever looked after somebody

who's had that many pacemakers, and I used to work in cardiology.

A pacemaker sends electrical pulses to the heart

to keep it beating regularly.

The device can significantly improve quality of life

and can be life-saving for some patients.

Okey dokey.

Nurse Emma calls on the junior medical doctor on shift,

Dr Kirsty Sneddon, to take a look at the problem area.

-Can I ask your name?

-Yes. Alan.

-Hello.

I'm Kirsty, one of the doctors.

Dr Sneddon is originally from Aberdeen,

but has been working at the Gilbert Bain for four months -

and it's certainly left an impression.

You do know the patients more, I feel,

just because you've got the time to take and get to know them

and often you're treating relatives, you know, so they'll come back in.

There is a huge community up here.

I think you feel that...

..from day one, when you come in.

In and outside of the hospital, there's that.

You feel at home. Yeah.

So what's been happening today?

I've just got a little bit of a leak.

So I've been hearing. How long's it been going on for?

Probably about a month or so, maybe a tiny bit longer.

OK.

How much fluid do you think's come out?

Just as much as is on the dressing?

Yeah, and a little bit more that was wiped up.

OK. And is it tender round...

-Yeah.

-..round here where I'm pushing?

-Not so much there, just mainly on the site.

-Just where it is.

-OK.

-There's always been this, like, this knot up here...

..which I presumed was the wires.

Because, I mean, I've still got wires in this side

from the other pacemakers.

It seems to be the actual site of insertion seems very healthy.

It seems to be a possible old site that's infected.

I'm unsure at this stage how deep the infection goes,

so I've called the consultant and together we'll see where we go.

He's been treated with antibiotics,

which seem to have been pretty effective,

so we're going to investigate it with some bloods and a scan

of the site to see if there's an abscess under the skin

and take it from there.

So, feeling a bit more relieved about it?

Yeah. Did you always want to be a doctor?

I did, actually.

Since about four years old. My grandparents were doctors,

so playing with stethoscopes and plastic syringes on a Sunday

at their house was quite normal.

-Shaving the cat.

-Yeah!

You had the tea set, you had the doctor set.

So, that's all the blood I'm going to take off you today.

I promise.

With bloods taken to double-check there isn't a deeper problem,

and Dr Sneddon happy that the antibiotics are taking effect,

Alan and Janine are allowed to return home.

-Okey dokey. Yeah.

-Just come back or call if you have any questions or

-issues or anything.

-Yeah, yeah. Brilliant. Thanks for your help.

-That's all right. See you later!

-Thank you.

-See you then. Bye.

It's the weekend and all over the islands,

Shetlanders are enjoying their Saturday,

which, for a lot of them, means sporting activities -

and sometimes a visit to A&E.

So, are you able to tell me exactly what happened?

Just going over the hill with my bike

and I pulled a wheelie and it flipped.

John's a fan of Motocross.

He is seeing A&E nurse Lauren Kerr after coming off his off-road

motorbike and crushing the little finger on his right hand.

John lives in Whiteness, nine miles north-west of the Gilbert Bain.

Oh, cos your foot hit into the...

Yes, I came off, then I came down on my foot and bounced off the ground

and knocked this out.

Nurse Lauren reports her initial assessment to Dr Ashley Thomson,

today's A&E surgical doctor.

So, he was on the hill on his motorbike,

doing a wheelie, and kind of lost control of the bike.

As you do!

And he says he kind of did the splits

and his right pinkie finger has hit into his foot

and it does look dislocated.

Where do you think it is dislocated, here or here?

-What do you think?

-Lower?

-Down there?

At the metacarpal?

Not that I am any professional.

And he's unable to move it.

-Hello!

-Hello.

-Mr Burns.

-That's me.

-Hello, how are you doing?

I'm doing wonderful. You?

Good. My name's Ashley Thomson, one of the surgical doctors.

I understand you've injured your finger.

-Got it bent.

-Tell me what's happened.

I just fell off me bike.

You were on a Motocross bike?

Yeah, and I just kind of pulled a wheelie and fell off

and when I fell off, this hand hit the back of my foot.

OK, fine.

And that was the result of that.

What we need to do is just confirm that on X-ray,

so we'll get a picture of it.

-OK.

-And then it looks like we're going to have to pull it

-back into place.

-Oooh.

-OK?

Super. I know.

Sounds worse than it is.

We'll get an X-ray then I'll come and explain fully what we'll do.

Yeah, that's no bother.

Can you feel me touching here?

-Mm-hm.

-And if I was to touch the other side, does it feel the same?

-Yeah.

-Yeah? Feel me touching there?

-Yeah.

-Feel the same there?

-Yeah.

-Yeah. Perfect, fine.

OK. It looks to me like it's this joint here that's been affected,

but we'll just make sure that there is nothing further...

-OK, yeah.

-..that's been injured there.

-Any questions at all with that?

-No, no. That's good.

Super. I'll go ahead and get that sorted for you, OK?

-Super.

-Perfect.

-Thank you very much.

-No bother at all.

A&E isn't busy and, after a short wait,

John gets his little finger x-rayed.

And as the Gilbert Bain uses digital technology for its X-ray imaging,

Dr Thomson gets the results swiftly.

So, you can see that all the other fingers...

Our fingers should be nicely aligned

and all in a nice, straight line together,

whereas this one has taken a step forwards here.

But you can see it more clearly on the lateral.

And you can see that it has just jumped forward,

so it's essentially shortened the finger down, so it's gone backwards,

and then it slipped upwards,

so we'll pull it back into position and give him a nice,

straight finger again.

I guess it's confirming what we thought, just on examination,

that it's dislocated there, so we'll go and let him know

and explain what we're going to do and pop it back into place for him,

get it all nice and straight.

Offshore rig worker Ryan has been brought into the Gilbert Bain after

suffering days of abdominal pain.

Dr Brennan and Dr Lalla are trying to diagnose Ryan's symptoms.

They'd thought that it might be appendicitis,

but due to Ryan's family history,

they now think it could be Crohn's disease.

Hi there.

-Hello.

-Ryan?

-Yeah.

-Hi there. How are you doing?

-Not too good, not too bad.

Not too good, not too bad.

OK. How old are you, Ryan?

19.

Crohn's disease affects over 100,000 people in the UK.

Most cases develop between the ages of 16 and 30.

When did this start?

Well, the pain started on...

..Sunday.

And it started with pain first, did it?

-Yeah.

-Right.

-Well, the pain had started on Sunday,

but everything had started on the Saturday.

Diagnosis involves history, examination and then tests

and, depending on what you find,

you constantly go back and forth,

deciding what your diagnosis is going to be.

It's usually a combination of factors,

looking at everything together, that helps you decide.

Right, OK. Just try and blow your belly up and touch my hand.

Try and blow it out as much as you can.

-That sore?

-Yeah.

Yeah. Let's do the opposite.

Let's try and suck it all the way in.

All the way in. That sore?

-Just a wee bit, yeah.

-Which is worse, blowing out or sucking it in?

-Blowing it out.

-Blowing it out.

So, what we are going to do, then, Ryan,

is get some blood tests just now.

-Yeah.

-They've taken some bloods off you.

-Yeah.

-We'll see what those show.

The question for us is whether we need to take you to theatre or not.

OK? Have you had anything to eat or drink?

Not since dinner time.

Don't have anything to eat or drink just now, OK? Until we tell you.

Blood?

White cells 13.7.

Yeah. Any thoughts?

-Appendicitis.

-Yeah, pointing towards appendicitis now, isn't it?

Right.

But, let's see.

We might still get caught out. It might be colitis.

Still don't know.

So, what we're going to do is get some x-rays on you just now

and then take things from there.

With Ryan's symptoms and initial blood tests now indicating possible

appendicitis, Dr Lalla must perform more tests to be sure.

There's two distinct possibilities.

After seeing and examining him,

appendicitis is very high on that list.

If it is appendicitis,

it may end up being quite a complicated appendicitis.

If it's not appendicitis, it's very likely to be Crohn's disease,

but we are now leaning more towards appendicitis,

given the examination findings and the bloods.

It is still not clear, though.

The question is whether we go on to take him to theatre

and open up the tummy, or not.

Eight of Shetland's inhabited islands

are connected to mainland Shetland

by the island's ferry service.

The ferry service connects the islands of Fair Isle, Foula, Fetlar,

Bressay, Unst, Whalsay and Yell.

Employing 103 people and operating 365 days a year,

the service is vital to Shetland's communities.

But working on such a service can bring with it

a lot of seafaring hazards.

Ferry worker Shona has come into A&E with a suspected broken ankle.

Shona tripped and fell while working on the ferry to and from Fair Isle.

Nurse Amanda Brown is first to assess Shona and her injured ankle.

So, what were you doing yesterday?

I was working in the hold of the boat.

OK.

And there's the floor...the bottom of the hold,

and then there's the sloping side.

And there's just like little loops that are kind of inlaid

just at the bottom of that edge, half in,

and I turned and caught my foot on that.

It twisted and went over.

So would you say you twisted it in?

-I'm not sure how.

-Do you think it went like this or like that?

It went in.

-Inversion?

-Yeah.

-OK.

Did you think you'd come down a step?

I didn't come down a step, I came down a slope.

Down a slope. OK.

Shona comes from Brae, which lies 23 miles north-west of Lerwick.

I'm a relief deckhand for the Shetland Council Ferries,

so I go around all the council ferries in Shetland.

And I went in on Tuesday to work until tomorrow.

Supposed to come out tomorrow.

Yeah, I was working and went over on my ankle in the hold of the boat.

There we go.

-Hi there. Is it Shona Williamson?

-Yeah.

-Hi, I'm Saul,

I'm one of the doctors here.

As the surgical doctor on shift,

Dr Saul Wilson and medical student Albert Myerscough need to determine

whether Shona has broken her ankle.

-It's quite sore.

-Yeah, no, I can imagine.

-So I'll have a little look...

-It's really, really tender around here.

-And here.

-Around there. Both sides.

-Just here, mostly.

-OK.

-It's not as sore as it was last night.

-Yeah. OK.

So I'm having a little feel.

Obviously, just let me know when it's painful.

I can tell from the look on your face, you don't want me doing this.

-OK, so there?

-That was sore, yeah.

That was sore, OK.

-Still tender when I'm pressing here?

-It's quite tender, yeah.

-OK.

How about here?

Yeah.

-That's not so bad.

-OK.

Right. Yeah, so I think we'll need to do an X-ray,

just to see if there's any fractures at all.

I guess it depends on what the x-rays show, what we do after that.

And just looking generally, I can't see anything too obvious,

but I think I'll probably run it past my senior just to check there's

nothing that I'm missing.

Dr Wilson's consultant confirms his assessment.

There is no fracture.

It seems Shona is off the hook.

Well, the x-rays look fine, so it must be a soft tissue injury.

I'll get him to come and speak to you before you go.

Are you happy for me to put on a Co-Plus support?

Yeah.

Now, if this feels too tight, then you just chop it off.

The bandage, not the leg!

There's just time to try out a set of crutches before Dr Wilson returns

to confirm the good news.

Hiya, how are you getting on?

-Fine, yeah.

-Good.

So, I think maybe the nurses have come in and told you.

We couldn't see any fractures, which is good news, yeah, yeah.

So it means you won't have to do anything too dramatic.

No surgery or anything, no manipulation.

But, yes, it will probably be tender for quite a while.

And, obviously, you probably won't be able to work for a little bit.

Yeah.

So you can rest a bit.

I'll try!

-Well, nice to meet you, anyway.

-Yes, nice to meet you, too.

-See you later.

-Thank you very much.

-No worries. Bye.

We'll go and find your mam.

-Yeah, she's somewhere around.

-Yeah.

With another patient successfully discharged,

nurse Amanda sees Shona out to the car.

It's all part of the Gilbert Bain service.

You're welcome. Bye.

-Job done.

-CAR ENGINE STARTS

On the road, 16 miles south of Lerwick,

John has arrived at his first stop in Levenwick.

So, this is Levenwick Health Centre.

First drop.

Get my little life-saver.

I'll come back for those.

Hello!

Just check that there's anything to go back.

That's just one sharps bin.

You can get one to half a dozen to 12.

And then the bags go inside that big bin.

But you can see it is separated from the back.

And then John's back on the road

with Bixter, 30 miles to the north-west, his next port of call.

We're off to Bixter now, over on the west side.

Everybody knows everybody, really.

You come across everybody at some stage in your time here.

The people that have been born and bred here, they'll know so-and-so

and they go, "Oh, I know so-and-so!" Yeah.

They just know everybody.

This is Bixter Health Centre.

The one and only drug stop.

These are vaccines. Well, I don't know what they are, actually.

There we go, young lady.

-Thank you.

-Thank you.

On the west coast, Walls Health Centre is John's last drop

and the sun finally shines on his day.

Oh, fabulous in Walls, yeah.

Yeah, fantastically sunny.

I can manage these without the trolley.

Hello. That's the one, that's done.

OK. That's it, then.

-Yeah.

-Thank you very much.

See you again. Bye.

With his vital medical jobs complete and deliveries done,

John heads back to HQ.

I'm back in the town centre.

And just heading to the hospital now.

Plan ahead for tomorrow

and discharge anything I've picked up today

back to relevant departments.

Yeah, back to HQ with the mail for the...

..community nurses.

Getting to live and work in Shetland

brings with it a certain appreciation.

Travel, outside...

..on days like this. Fantastic.

Although, on horrendous days, it can be good.

Yeah.

John Burns from Whiteness has come into A&E

after hurting his hand falling off his Motocross bike.

Dr Thomson has had his hand x-rayed and confirmed her diagnosis.

It's time to tell John.

-Hello, John.

-Hello.

That X-ray confirms what we were speaking about.

-OK.

-It's dislocated out of the joint space here and it's gone forwards,

so this bit of the finger, instead of being in a nice,

-straight line here, has jumped forwards and has gone back.

-OK.

So essentially, that's why this finger's shorter

-than your little finger on this side.

-Uh-huh.

So what we'll do is put that back into the right position.

-You just do what you have to do.

-Is that OK?

-Yeah, yeah.

-Carry on.

-Do you want to lie down for it?

You've got laughing gas and all!

Do you think... Do you want to lie down?

-I'm not fussed. Whatever you want me to do.

-Are you OK with needles?

-Yeah, yeah.

-Yeah?

Yeah, that's probably... That's actually probably quite helpful.

You hold on to that.

INAUDIBLE

A wee bar to stick in my mouth or something?

We'll give you the gas and air that you can pop in.

So it's this stuff that'll make you happy, then?

-It's called laughing gas.

-HE TAKES A DEEP BREATH

Well, wait till we do something first!

Otherwise we'll just be...

-Just be giggling.

-Just be merry!

Before we've done anything.

Save a hangover, would it not?

Just going to give the skin a little bit of a clean, OK?

-INAUDIBLE

-Yeah, that would be good, actually.

So you've got the Entonox there, so just puff away on that

as you need to, OK? Okey doke?

-Ready for me to start?

-Yeah.

Sharp scratch. Well done.

This laughing gas is kind of kicking in a bit.

So, I'm just going to pull this back into place now.

Well done. OK.

-That's it.

-Keep blowing, in and out.

-Is that it?

-Yeah, that's it.

-That's it.

-That's good stuff.

-Did you feel...

-I like that stuff!

-You can feel it going back into place, probably.

-Yes, I can feel it popping.

-It's a little bit of a...

Yeah, a clunky type of noise.

-Jeezo, that stuff works.

-Well done! That's it.

Are you feeling a bit funny?

And then you can see that the finger,

it's lengthened back up to the length that it should be

and that it's now back in the right joint space

and moving quite freely there.

All that's left is a precautionary X-ray

to check if John's pinkie is in full working order.

OK, we are all done.

That's good. I'm pleased it's nice and back in the joint,

but it definitely felt like it went back into the joint,

so that just confirms that,

so we can go and let him know that he's got two good fingers now.

Ten good fingers, actually! Ten fingers.

It's back in the joint.

Looks better when it's meant to be in the right place.

Yeah, and it looks perfect on the X-ray.

So I'm pleased with that. What we'll do is

we'll strap it to your next-door finger.

-OK.

-It's called buddy strapping.

-Oh, boy.

-So, we'll just strap it here and strap it here,

and that just is to give it a bit of extra support.

-OK.

-And it's to try and limit the amount of mobility

through that finger for the next couple of weeks.

-Super.

-Is that OK?

-Thank you very much.

-Any questions at all?

-No.

-No?

-No, that's wonderful.

Perfect. So we'll just strap it up and then you're free to go.

And with that, John is left to enjoy the rest of his weekend.

19-year-old offshore worker Ryan was medevac'd to the Gilbert Bain A&E

suffering from abdominal pain.

He's been sent to have his stomach and bowels x-rayed in an effort

to diagnose his condition.

OK, that's the first one done.

And breathe all the way out.

Hold your breath.

And breathe away.

Having thought Ryan had appendicitis,

Dr Lalla has now had a full set of blood results back.

One of the inflammatory markers, something called the CRP,

has come back normal, completely normal.

Usually, if this has been going on for three days, by now

we would expect the CRP, if it was appendicitis, to be quite high,

at least two or three hundred.

So it means everything we thought so far, we have to go back and revisit.

Not even Crohn's. It's very unlikely to be either of them now.

Dr Lalla visits the X-ray department to check on Ryan's results.

There is some faecal loading over here.

The x-rays are fine.

Your bloods, actually, surprisingly, are OK.

What we want to do is keep you in, keep an eye on things,

and see how you go.

-OK.

-Right, but it doesn't look like there is anything nasty going on at

the moment. OK?

-That's good news.

-It is good news for you, but what it means is,

long-term, you need to change your diet.

-Yeah.

-Well, we'll get you up to the ward, take things from there,

and see how you go.

The more senior you become,

the more you start to realise that things are not clear-cut.

The more you know, the more you realise you don't know.

He looked very clearly like possible appendicitis or something called

Crohn's disease, colitis, but it wasn't.

So what it means is that you should go back and revisit that history and

start to consider alternative diagnoses

that you may not have considered the first time round.

Next thing to do is to make sure

that there's nothing underlying that.

So, what could be causing constipation

in a young guy like this?

We will want to do a few more tests to decide if there's anything

underlying that.

With surgical intervention avoided,

Dr Lalla and the staff of the Gilbert Bain

will be keeping a close eye on Ryan over the next 24 hours.

Hospital porter John is still travelling

the length and breadth of Shetland.

Crofter Andy's hand healed successfully

and he managed to shear the rest of his sheep.

And after spending the night in the Gilbert Bain,

Ryan is back to full health and getting ready to head back offshore.